Probus Club Membership Application Form – Australia
I hereby apply for membership of the Probus Club of Hollywood Kings Park ____
Title: Surname:
Given Names: Preferred Name on Badge: _______
Spouse/Partner Name: _____________
Date of Birth / / Email Address: _______________________________________
Address: _______________________ Postcode:
Telephone: Mobile: ____________
Former Vocation: ___________
________
Hobbies, Sporting & Other Interests:
_
In case of emergency, please contact:
Emergency Contact Telephone: _______________ ________
_________________________________
___________________________________
- I agree to be bound by the provisions of the Club’s constitution, by-laws and/or standing resolutions and agree to take an active role in the Club through my attendance and participation.
- I understand that the information provided in this application will be used to assess my application and maintain my membership. I understand that my application may not be processed if any of the above information is not provided.
- I acknowledge that at some time during my membership, I may be called upon to take an active role on the Management Committee.
- I consent to my name, address, telephone number and email address being included in the ‘Directory of Members’ to be distributed only to members of the Club.
- I understand that I may access any personal information the Club holds about me upon request.
- I accept that the information provided in this application form will be provided to Probus South Pacific Limited (PSPL) in accordance with the PSPL Privacy Policy which can be viewed on the PSPL website.
- I understand that the minimum information required by PSPL is my first name and last name and that it is my responsibility to advise the Club Secretary in writing if I do not want PSPL to hold any of the additional information in this application form or I do not wish to be contacted by PSPL.
- I understand that the Club has Public Liability Insurance of $20 million through PSPL and that I can access a summary of this coverage through the Club Secretary or the PSPL website.
- I understand that the Club may publish photographs of its members on its website, in its newsletter and/or on social media to promote the Club and its events. By signing this application form, I consent to the publication of such photographs unless I have advised the Club Secretary in writing that I do not consent to such publication.
- I understand that the Club Secretary may provide photographs of its members for use in PSPL’s publications, website and/or social media. By signing this application form, I consent to the publication of such photographs unless I have advised the Club Secretary in writing that I do not consent to such publication.
- I agree to receive the Active Retirees E-newsletter published by PSPL and understand that I can unsubscribe from the E-newsletter at any time.
Applicant’s Signature _____________ Date: ___ __
Sponsored by*: ______ Signature: _______ Date: ____
Sponsored by*: ______ Signature: Date:
*MEMBERSHIP APPLICATIONS MUST BE SPONSORED BY TWO FINANCIAL MEMBERS OF THE CLUB. FOUNDATION MEMBERS OF NEW CLUBS DO NOT REQUIRE SPONSORS.
Issued by Probus South Pacific Limited ACN 152 374 395 – May 2018
HOLLYWOOD KINGS PARK PROBUS CLUB
CLUB USE ONLY
PLEASE NOTE: DIRECT DEBIT PREFERRED
Payment Administration Details
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Notes:
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Direct Account Details: Commonwealth Bank
Hollywood Kings Park Probus Club
BSB: 066-103 Account No: 10491448
®